When should dexamethasone (corticosteroid) be resumed after discontinuation?

Resuming Dexamethasone After Discontinuation

Dexamethasone should be tapered rather than abruptly discontinued to prevent adrenal insufficiency, and if resumed after discontinuation, it should be restarted at the previously effective dose with careful monitoring for recurrence of symptoms. 1

General Principles for Resuming Dexamethasone

• Corticosteroid therapy duration should be minimized to prevent long-term sequelae, but when needed, it should be tapered rather than abruptly discontinued due to the potential for adrenal insufficiency 1
• When resuming dexamethasone after discontinuation, consider the original indication, duration of previous therapy, and time since discontinuation 1
• Monitor patients closely after discontinuing corticosteroids, as inflammation may recur, especially when stopped abruptly 1

Specific Scenarios for Resuming Dexamethasone

For Brain Metastases/Cerebral Edema

• If symptoms of cerebral edema recur after discontinuation, resume dexamethasone at 4-8 mg/day for moderately symptomatic patients 1
• For patients with marked symptomatology, mass effect, or elevated intracranial pressure, higher doses (16 mg/day) may be warranted 1
• Dose should be based on symptom severity, with lower doses preferred to minimize side effects 1

For Bacterial Meningitis

• If dexamethasone was discontinued after identifying a pathogen other than S. pneumoniae or H. influenzae, but clinical deterioration occurs, consider restarting dexamethasone within 4 hours of antibiotic administration 1
• For pathogens like N. meningitidis where there appears to be no harm or benefit, the decision to restart can be made on an individual basis 1

For Vestibular Neuritis

• If symptoms recur after discontinuation, resume oral dexamethasone 10 mg/day for 5 days, followed by a tapering dose over the next 5 days 2
• Treatment benefits diminish when initiated after 72 hours from symptom onset, though some benefit has been reported up to 6 weeks 2

Monitoring After Resuming Dexamethasone

• After resuming dexamethasone, monitor patients for:
  • Hyperglycemia and electrolyte abnormalities 1
  • Sleep disturbances and psychiatric adverse effects 2, 3
  • Signs of infection due to immunosuppression 1
  • Potential for osteoporosis with prolonged use 1

Duration of Resumed Therapy

• For cerebral edema: Continue until symptoms resolve, then taper gradually 1
• For bacterial meningitis: Continue for the originally planned duration if resumed within the first 24 hours of treatment 1
• For most conditions: Minimize duration to prevent long-term sequelae 1

Tapering Considerations

• Corticosteroid-induced adrenal suppression is duration-dependent, and patients who received longer courses (>14 days) might particularly benefit from a taper before discontinuing 1
• In patients with brain metastases, corticosteroid therapy should be tapered rather than abruptly discontinued given the gradual improvement of edema with oncologic therapy 1
• For patients who deteriorate after stopping corticosteroids (such as development of shock or need for mechanical ventilation), reinitiating corticosteroid therapy could be helpful 1

Common Pitfalls to Avoid

• Underdosing is a common pitfall - ensure adequate initial dosing when resuming therapy for maximum benefit 2
• Abrupt discontinuation can lead to adrenal insufficiency and recurrence of symptoms 1
• Failing to monitor for side effects, particularly in patients with pre-existing conditions such as diabetes 2
• Not considering drug interactions when resuming dexamethasone, especially with medications that may prolong QT interval 1